Prior Authorization Specialist

Southwest Womens Oncology Inc•Albuquerque, NM

46d•Onsite

About The Position

The Prior Authorization Specialist obtains timely insurance authorizations for clinic-based infusion therapies—including chemotherapy, immunotherapy, biologics, and supportive medications—surgical procedures, and oral and specialty medications. The role ensures patients receive medically necessary care without delays across Southwest Women's Oncology and Optimum Infusion. The specialist reviews orders and supporting documentation, submits requests through payer portals and other channels, tracks active requests, and follows up with insurers. The role coordinates with providers, clinical staff, nurses, infusion and surgery schedulers, pharmacy, billing, and coding teams to secure authorizations before treatment, procedures, visits, or medication dispensing. It also communicates authorization decisions, coordinates peer-to-peer reviews and appeals, maintains accurate records, and complies with HIPAA, organizational policies, and payer regulations. This is a full-time, on-site position at the Albuquerque, New Mexico office. The organization emphasizes patient-centered care, accuracy, urgency, ownership, teamwork, accountability, continuous improvement, and professional growth.

Requirements

High school diploma or equivalent.
At least 2 years of prior authorization experience in healthcare revenue cycle.
Demonstrated experience with medication and procedural authorizations.
Knowledge of commercial insurance, Medicare, Medicaid, and managed care plans.
Proficiency with EMR systems and insurance payer portals.
Strong organizational skills and ability to manage multiple active authorization requests simultaneously.
Excellent written and verbal communication skills with a patient-centered approach.

Nice To Haves

Associate's degree preferred.
Prior experience in a clinic, outpatient specialty practice, or ambulatory surgery setting.
Experience with oncology, infusion services, or surgical scheduling workflows.
Knowledge of oral oncolytics and specialty pharmacy coordination.
Familiarity with CPT, HCPCS, and ICD-10 coding and medical necessity documentation.

Responsibilities

Obtain prior authorizations for infusion therapies, surgical procedures, and oral and specialty medications.
Submit authorization requests through payer portals, electronic systems, phone, and fax with complete, payer-compliant documentation.
Track active authorization requests and proactively follow up with insurance carriers to secure timely determinations.
Ensure authorizations are in place before scheduled infusion appointments, clinic visits, surgeries, and medication dispensing.
Review provider orders, clinical notes, operative plans, and supporting documentation for completeness and payer compliance before submission.
Verify insurance benefits, coverage criteria, and payer-specific requirements, including step therapy, site-of-care rules, and clinical guidelines.
Maintain accurate, current documentation in the EMR and authorization tracking systems.
Stay current on payer policies, clinic workflows, and regulatory standards affecting outpatient services.
Communicate approvals, denials, and pending requirements clearly and promptly to providers, nurses, surgery schedulers, pharmacy, and front-desk teams.
Coordinate peer-to-peer reviews and appeals with providers and leadership when authorizations are denied or delayed.
Collaborate with billing and coding staff to ensure authorized services align with CPT, HCPCS, ICD-10 codes, and payer requirements.
Maintain compliance with HIPAA, organizational policies, and payer regulations.